The Surgery of the Skull and Brain

by Louis Bathe Rawling

In all these, and in other doubtful cases, before undertaking surgical procedures, the surgeon should obtain the services of a skilled neurologist.

The clinical course of the case.

If a typical case of Jacksonian epilepsy can be observed from beginning to end, many curious and interesting features will be observed. The fits, at first typically Jacksonian, gradually lose their typical character, becoming more frequent and less focal in nature, the patient losing consciousness during the fit, and the fits succeeded by weakness or paralysis of the parts primarily involved. The general mental state of the patient suffers proportionately—he becomes morose, despondent, irritable, homicidal, or suicidal in tendency. How far these retrograde symptoms are dependent on degenerative processes in the brain, and how much they result from the moral effect of the frequent epileptiform seizures, are questions that can only be determined by observing the effect of treatment, surgical or otherwise. Some cases respond readily to treatment, others are too far advanced to experience any material benefit, some end their days in the lunatic asylum.

In any case, surgical treatment, if adopted at all, must be carried out before definite brain-degeneration arises—such changes being evidenced by spasticity of the limbs, exaggerated knee-jerks, &c. When such pathological changes are existent, there can be but little hope of benefiting the patient.

Further points in the clinical course of the case, and such also as throw further light on the pathological conditions present, will be obtained by a survey of 21 cases that have come under my own care or close observation.

Time elapsing between the date of the accident and the first fit.
	Between 1 and 19 years			9 cases
	Within 8 months			9 cases
	After a few days			1 case
	Uncertain			2 cases
Age at time of accident.
	Before 15, 12 cases. Youngest, 3 years.
	After 15, 9 cases. Oldest, 55 years.
Sex.
	Males 20. Females 1.
Conditions found on external examination and on operation.
	External examination:		Depression of bone and scar, 6 cases.
			Deficiency of bone, 3 cases.
			Scar only, 5 cases.
			Nil, 7 cases.
	At operation:	Sclerosis of bone, 1 case.
		Tuberculous mass, 1 case.
		Subdural cyst or hæmatoma, 8 cases.
		Scalp adherent to dura, 3 cases.
		Scar in brain, 1 case.
		Œdema of brain, 3 cases.
		Nil found, 1 case.

Some lesion, such as might be accepted as responsible for the development of the fits, was discovered in 17 out of 18 cases. Duret’s experience tends to bear out the view that some pathological lesion will be found in almost every case. In 67 cases reported the following conditions were found:—

Depression of bone, 27 cases.
Splinters of the internal table, 15 cases.
Cysts, subdural, 4 cases.
Thickening of membranes, 7 cases.

Operation.

When the localization of the trouble is suggested by the presence of focal symptoms, and by a corresponding scalp- or bone-injury, no difficulty need be experienced in determining the site of exploration. When the fits are associated with definite focal symptoms, but without the supplementary evidence obtained by visible signs of external injury, exploration should be conducted over that region of the brain from which the fits appear to emanate. In the absence of all localizing brain symptoms, operative measures should be carried out over the site of scalp or bone lesion.